Cranio-cerebral and vertebral-spinal injury

Cranio-cerebral injury
Frequency of cranio-cerebral injuries is more than 200 cases per 100,000
populations per year. It is divided into the closed craniocerebral injury and opened,
which skull cavity communicates with environment and increases the probability of
infectious complications. The closed craniocerebral injury is more frequently
encountered in peacetime. Handling patients with open craniocerebral injury is the
scope of neurosurgeons and traumatologists. In the present division are discussed
predominantly the questions, connected with the closed craniocerebral injury.

Classification and pathogenesis. The damage of brain can be caused by directly

traumatic action in the region of the impact and on the opposite side in the place of
shock, by diffuse axonal damage, and also by intracranial complications
(hematoma, infection, brain edema) or by the appearing with the injury somatic
disturbances (arterial hypotension, the disturbance of respiration and others), which
lead to hypoxia brain.

Depending on morphology of brain damage, it is divided into brain contusion, brain

injury, diffuse axonal damage and intracranial hematoma. Brain contusion - necrotic
bruiseing of the sections of cortex and white substance, usually combine with small
hemorrhages and brain edema. Brain Concussion is acute shaking with injury of
head without macroscopic changes with the reversible disturbance of functions,
which is connected with mild degree of diffuse axonal damage. Intracranial
traumatic hemorrhages on the basis of localization are divided into epidural,
subdural and intra-cerebral hematomas.

To understand the mechanism of injury, it is important to know the fact that the
cerebral hemispheres is surrounded by cerebrospinal liquid, are capable of moving
in cavity of skull separated from bone structures. If appears acute impact, which
sets of head to the motion, cerebral hemispheres is holdup behind the motion of
bone structures, on the contrary, if it strikes against fixed object, the motion of
cerebral hemispheres anticipates the motion of bone structures. In both cases as a
result of the rotary motion of hemispheres appears their deformation (twisting) of
the relatively rigidly fixed stem of brain, which is maximally expressed at the level
of the upper divisions of the reticular formation brain stem, which causes the loss of
consciousness. The forces of rotation divide or tear up the axons of nerve cells in
the white substance and the stem of brain (diffuse axonal damage). Furthermore,
with the rotary motion of hemispheres their surface formations are damaged from
the contact with the bones of skull and the folds of dura mater, which leads to the
development of softening (injury of brain) and hemorrhages both in the point of
impact and on the opposite side in the place of shock. Diffuse axonal damage
explains the loss of consciousness after the injury in the absence of the anatomical
damages brain according to the data of CT or MRI of head.

Mild, average and severe craniocerebral injury is separated according to the degree
of the disturbance of consciousness after injury. The mild craniocerebral injury, at
basis of which usually lies the contusionor mild contusion brain, composes majority
(80%) of all cases of craniocerebral injury. It usually it is not life-threatening, but
frequently causes the consequences, which decrease the quality of life.

The fracture of the bones of skull more frequently occurs with the severe
craniocerebral injury, but it is possible with its mild degree. The presence of the
fracture of the bones of skull significantly increases the probability of intracranial
hemorrhage. The fracture of bones of the base of skull is connected with the risk of
damage to carotid artery, optic nerve and other cranial nerves, entry into the cavity
of the skull of air (pneumo-purpose) and infection (meningitis, encephalitis), and
also risk of a constant escape of cerebrospinal liquid into the paranasal sinuses
(rhinorhea) or the ear (otorrhea).

Epidural hematoma appears as a result of hemorrhage from the damaged

meningeal artery (a. meningia media) or it is less frequent than the vein, with the
break of temporal or parietal bone. Subdural hemorrhage appears as a result of the
defeat of the veins, which connect the venous system of brain and the sinus of dura
mater. An increase in the intracranial pressure with the venous hemorrhage can
lead to its stoppage and formation of chronic subdural hematoma. More frequent
subdural hematoma is formed above the surface of hemisphere, frequently from
both sides. In the majority of the cases of contusion brain appears sub-arachnoidal,
and frequently also subdural hemorrhage.

Clinical picture. Craniocerebral injury causes the disturbance of the

consciousness, degree and duration of which determine its prognosis. The rapid
restoration of consciousness after injury testifies in favor its mild degree. The more
prolonged the loss of consciousness, the more probable the contusion brain or the
intracranial hemorrhage. During the disturbance of consciousness gravity injury it is
convenient to determine according to Glasgow Coma Scale (GCS). If the sum total of
marks composes 13-15, then craniocerebral injury they estimate as mild, if 8-12 - as
average, if 3-7 - as severe. The average and severe degree of craniocerebral injury
indicates the high probability of the injury brain and/or intracranial hematoma; for
example, subdural hematoma of happens in 20% of patients with severe
craniocerebral injury. On the contrary, mild craniocerebral injury in the majority of
the cases is caused by the contusionof brain, the probability of epidural and
subdural hematoma composes respectively 0,5 and 1 %. In severe craniocerebral
injury, rapid death can begin as a result of the disturbance of the function of the
respiratory center of the medulla oblongata.

Glasgow Coma Scale (GCS)

Index Marks
Opening of the eyes:
spontaneously 4
in response to voice 3
in response to painful stimuli 2
Does not open eyes 1
Speech:
Oriented. 5
Confused. 4
Inappropriate words. 3
Incomprehensible sounds. 2
 No verbal response 1

Motor response:
Obeys commands. 6
Localizes to pain 5
Flexion/Withdrawal to pain 4
Abnormal flexion to pain 3
Extension to pain 2
No motor response 1

In inspection of patient, it is important to exclude the presence of fracture of bones

of skull, and also break of spine and extremities, damages of internal organs. The
fracture of the bones of the arch of skull can be revealed during the visual
inspection and the palpation. Hemorrhage from the nose and the external auditory
passage, hematoma into the region of temple or mammiform branch after the ear
(Battle’s signs), the double-sided bruise in the orbital region (symptom of glasses)
they indicate the possibility of the fracture of the bones of base of skull, although
they can be the consequence of local injury. Expiration of cerebrospinal liquid from
the nose (rhinorhea) and the ear (otorrhea) testifies about the fracture of the bones
of the base of skull. The fracture of bones of skull with mild craniocerebral injury
increases the probability of intracranial pathology (hematoma, infection) .

During neurologic inspection, they explain the presence of the symptoms of the
focus of brain lesion: weakness of extremities, sensory disorder, disturbance of
coordination and others. They testify about the structural defeat brain: injury and/or
hematoma. The detection of meningeal symptoms indicates the probability of
traumatic sub-arachnoidal hemorrhage, and if they appear several days after injury,
assumes infectious process (meningitis, encephalitis). The defeat of olfactory nerve
indicates the fracture of ethmoid bone, defeat of facial nerve indicates break of the
pyramid of temporal bone.

While inspecting in the hospital, it is necessary to exclude the damage of other

organs, especially organs in abdominal cavity, chest, spine and tubular bones,
which are most probable in the case of persistent arterial hypotension (decrease in
systolic arterial pressure below 90 mm Hg).

Diagnosis. In the cases of the mild craniocerebral injury, when there are no signs
of the fracture of bones of skull and changes with the neurologic inspection, and
also there are no risk factors of hematoma in injury of head (method of
anticoagulants or pathology of blood coagulability), it is possible to limit primary
inspection by the X-ray of skull and, if it does not reveal changes, then we do not
carry out CT of head. These patients must be observed in the course of several
weeks and if worsening of state, then CT or MRI of head is done.

In the remaining cases special CT of head is necessary. If there is no possibility to

conduct CT or MRI of head, then are carried out the X-ray of skull,
echoencephaloscopy, fundoscopy , also, if suspects hematoma (increasing
worsening of state, fracture of the bones of skull in X-ray, displacement of the
middle structures brain with echoencephaloscopy, stagnant disks and hemorrhage
into the retina on the fundus) can be superimposed diagnostic of trepanning holes.
Lumbar puncture is not recommended because of the danger of the wedging brain
but it can be done with the suspicion to meningitis after according to data of CT or
MRI to exclude the volumetric damage brain. The X-ray of the neck division of spine
is necessary in signs of neck damage. In patient with craniocerebral injury, inspect
clinical and biochemical analysis of blood (electrolytes, glucose, coagulogram,
exponential functions of the liver and kidneys), total urine analysis.

Diagnosis of brain concussion is based on the short-term (second or minute) loss of

consciousness after injury, the absence of neurologic disturbances and changes
with the X-ray of skull and/or CT of head. contusion of brain are manifested possibly
by headache, vertigo, nausea, vomiting and amnesia to the events of injury. Usually
in the course of several hours or days, state is normalized; however, in some cases,
who endure the contusion of brain, the post-concussion syndrome is developed,
which can be the reason for more prolonged disablement. Patients with the mild
craniocerebral injury must be observed in the hospital during 5-7 days.

Diagnosis of mild traumatic brain injury (MTBI) (brain contusion) is based on the
prolonged (minute, hours or less frequent days) disturbance of consciousness after
injury, the presence of focus of neurologic disturbances (aphasia, central
hemiparesis and others) and is confirmed by results CT or MRI of head. Contusion
brain frequently is combined with intracranial hematoma, which can develop
gradually; therefore in worsening state of patient with the contusion brain, repeated
CT or MRI of head is required to detect possible development of hematoma.

Diagnosis of epidural and acute subdural hematoma is based on the progressive

worsening state of victim immediately after injury or through the small (minute or
hours) “bright space”, which appears following the initial loss of consciousness, and
confirmed by results CT or MRI of head. In epidural hematoma, frequently appear in
patients contralateral hemiparesis and homolateral (less frequent contralateral)
injury of oculomotor nerve with mydriasis, and also epileptic fits. Similar clinical
symptoms can be observed, also in acute subdural hematoma. In cases of subacute
(development of symptoms in the period of 2 to 14 days) or chronic (appearance of
symptoms after 14 days) course of subdural hematoma is observed prolonged
“bright space” after injury, and then usually appear headache, focus of neurologic
disturbances (aphasia, central hemiparesis and other), epileptic fits and disorder of
consciousness.

Chronic subdural hematoma frequently cause complexities in diagnostics, because

it can develop through the continuance (months and even years) after the mild
craniocerebral injury, presence of which the patients frequently forget. This
situation is characteristic for the elderly people, and also for the patients, who
assume anticoagulants. In all cases of suspicion of traumatic subdural hematoma, it
is necessary for special CT or MRI of head, which makes it possible to place
diagnosis. In absence of timely treatment, majority of patients with traumatic
intracranial hemorrhage die as a result of edema of brain and compression of its
stem. Small subdural hematomas can be reduced independently, but these patients
require a constant observation of neurosurgeon and repeated CT or MRI of head to
affirm the favorable course of disease.
All patients with the craniocerebral injury must be hospitalized into the
neurosurgical hospital in case of the need for conducting the special operation,
which is capable of saving the life of victim.

Prognosis, period and complication of craniocerebral injury. The prognosis

of craniocerebral injury is determined by its gravity, presence of combination
injuries and diseases, age of patient, rapidity of medical aid. Period of severe and
average gravity of the cranio-cerebral injury can be complicated by arterial
hypertension or by hypotension, heart arrhythmia, lungs edema, aspirative
pneumonia, embolism of pulmonary artery, disseminated intravascular coagulation
syndrome and other.
In severe craniocerebral injury, about 50% of the patients die, and 20% of patients
develop chronic vegetative state or severe neurologic defect
remains.

In the injury of head of severe degree, frequently in the first hours or during the
days after injury it death begins. In some patients after long period of disturbance of
consciousness, vital important functions are normalized, patients open eyes, the
sleep-awake cycle is restored, but they are deprived of cognitive functions and of
normal reaction (chronic vegetative state). In some patients, the restoration is
better than in patients with chronic vegetative state, but persistent neurologic
disturbances remain (central hemiparesis, aphasia and other). In majority of
patients with the injury of head, gradual restoration neurologic of functions is
observed, usually most significant during first 6 mo. from the moment of injury. In
some patients after contusion brain, personality changes appear and reduction in
intellect, which entails serious problems in their social and everyday adaptation. In
these cases the observation and treatment with psychiatrist is required.

Post-traumatic epilepsy appears on average in 5% patients, it is more frequent in

patients with contusion brain and/or hematoma, in the majority of the cases, large
convulsive fits are observed.

Post-concussion syndrome is manifested by headache, vertigo, disturbance of sleep,

irritation, reduction in concentration or attention, worsening of memory, increased
fatigue and decrease of fitness for work after the transferred craniocerebral injury.
It appears more frequently after mild craniocerebral injury (concussion or mild
injuries of brain), its origin is unclear, is assumed the role of mild diffuse axonal
damage and psychogenic factor. The more time passed after injury, the more
probable the role of psycho-social factors or compensation relations in genesis of
presentation of patient complaints (judicial trial, formulation of disablement). The
year after mild craniocerebral injury, there maybe manifestations of post-
concussion syndrome (most frequently headache, vertigo, the increased fatigue)
remain in 10-15% of patients. In progressive worsening state of patient, remember
about the possibility of chronic subdural hematoma and other complications, and for
diagnostics repeated CT or MRI of head is needed.

Treatment. Rendering to special aid to patient with acute craniocerebral injury is

directed toward the guarantee of passage of the respiratory tract, stabilization of
arterial pressure and the struggle with shock and its development. Special
hospitalization of patient into the neurosurgical department is necessary. While
transporting patient in unconscious state, the immobilization of neck division is
required and caution with the displacement of patient due to probability of an injury
of the neck division of spine, who frequently appears, especially in severe
craniocerebral injury.

Its surgical removal is done in epidural or subdural hematoma. During the intra-
cerebral hemorrhage, the operation is indicated in large, accessible for the surgical
intervention hematomas, which cause the displacement of cerebral structure or
severe neurologic disturbances, and also in the cases of the ineffectiveness of
conservative therapy.

In contusion brain, and also in patients with intracranial hemorrhage (if surgical
treatment is not accomplished) the conservative therapy is conducted, directed on
the guarantee of normal respiration, stable arterial pressure and the preventive
measures of complications. General care of patient has great significance. In
increase intracranial pressure and edema brain, use hyperventilation, IV 100-200 ml
20% mannitol solution (with need every 4-6h), and when the effect is possible of IV
is absent, the introduction of barbiturates. For an improvement in the metabolic
processes in the brain and its blood supply it is possible to employ Cavinton (15-30
mg/day inward or IV), nimodipine (120 mg/day inward or IV), Piracetam (4-12 g/day
inward or IV), Cerebrolysin (10-50 ml/day IV drop) and other neuroprotective means
(however their effectiveness it is not proven) .

In development of meningitis, initiate antibiotics. They use also with the preventive
purpose with the open craniocerebral injury, especially with the expiration of liquor
(rhinorhea or otorrhea).

In contusion of brain, bed rest is recommended whose duration (from the twenty-
four hours to several days) is determined individually, and symptomatic treatment
is carried out (analgesics, sedative means and others). Dynamic observation of
patient are important, since after “bright space”, it is possible the development of
hematoma. Many patients, who after injury do not have any objective disorders,
complain about the headache, vertigo, sleep disturbance and poor health, which in
majority of the cases is connected with increased anxiety or depression as reaction
to injury and with the special feature of personality (premorbid neurotic or
depressive type of personality). In these cases the tranquilizers or antidepressants
can help.
In the development of epileptic fits, a constant method of anticonvulsive means is
recommended. In more than in 50 % patients fits cease and the gradual withdrawal
of anticonvulsive means under the control is possible with control of EEG.

In post-concussion syndrome, rational psychotherapy are practical, gradual increase

in the load, If increased anxiety, tranquilizers are effective, in depression -
antidepressants with individually selected dose. One should tell patient about the
high probability of a gradual improvement in the state, recommendations on how to
return to the work and to the usual method of life faster. In expressed emotional
disorders, consultation psychiatrist is suggested. Post-concussion syndrome is
encountered more frequently and stayed longer in those cases, when in the
connection with the injury of goal, you appear in judicial trial, and/or there is
possible compensation for caused patient damage. On this regulating the juridical
problems, connected with injury, it relates to the important components of the
rehabilitation of patient with the post-concussion syndrome. On the contrary, long
period of court trial, repeated numbers of feudatory studies only increases the fear
of patient and decrease his motivation to return to the work.

Vertebral-spinal (spinal) injury

Pathogenesis. In peacetime, injury of spinal cord usually appears as a result of
falling, unsuccessful diving into water, car wreck. It occurs due to the compression
of vertebrae in the vertical plane in the combination with the rapid excessive flexion
or straightening of head (antero or retrohyperreflexion). As a result, joints of spine
break and displacement of upper vertebrae forward according to the relation to
inferior part, that usually causes the break of body or arcs of vertebrae, also, as a
result of this - crushing of spinal cord. Severity of injury is increased when there are
associated degenerate-dystrophic changes in the spine or innate narrowing of
vertebral channel is present.

Clinical picture. As a whole, the injury of spinal cord is manifested by paraplegia

or tetraplegia with paralysis of sphincters and loss of sensitivity of lower than defeat
level. Symptoms depend on defeat level.

Damage of spinal cord at the level of upper neck segments (C1-C3) cause cessation
of respiration and immediate death, if mechanical ventilation of lungs is not
conducted. In lower level of lesion, tetraplegia or lower paraplegia is observed, with
sensory loss of conductor type lower than defect level and pelvic disorders. In the
first hours after trauma, symptoms can increase, for example, from appropriate
tetraparesis to tetraplegia due to the development the edema of spinal cord.

In the stage of spinal shock, which appears immediately after trauma, all forms of
reflexes of lower than damage level disappear, urine incontinence appears because
of the atony of the bladder, paralytic intestinal impassability as a result of the atony
of bowels is possible. Subsequently (through 1- 2 weeks, sometimes later) the stage
of spinal shock begins to change gradually by the stage of increased vagal reflexes
in the parts of the bodies, which are innervated by neurons of lower than damage
level. In patient, pathologic flexible reflexes (Babinski symptom, shielding reflexes)
appear and then increase tendinous reflexes, tone of the bladder and bowels
increases. The hyper-reflection of the bladder is expressed by frequent and
imperative urges to urinate, automatic emptying with small filling. In complete
damage of spinal cord, the paralyzed lower extremities are crooked. In lesion of
cervical enlargement, muscle of the paralyzed hand or fingers atrophies and
reflexes disappear.
The degree of restoration is determined by the prevalence of defeat over diameter
of spinal cord. In its partial damage, usually it is observed gradually, the most
significant in the first 6 mo., restoration of motor, sensory and pelvic functions.

Diagnosis is based on clinico-anamnestic data. X-ray of spine, CT and MRI have

great significance to determine break and displacement of vertebrae, volume of the
lesion of spinal cord.
Treatment. Patients must be located in the traumatological or neurosurgical
departments, which are specialized in the spinal injury.
The treatment of breaks and displacement of spine relates to the scope of
traumatologists and consists of orthopedic elimination of subluxation and fixation of
spine. The effectiveness of laminectomies, and also high doses of corticosteroids for
the purpose of the decompression of spinal cord in trauma is not completely proven.
In patient with transferred spinal injury, therapeutic gymnastics and gradual social
and daily adaptation help.

Brief information about the closed craniocerebral injury

Brain Brain Injury Intracranial hematoma
Concussion (Contusion)
Pathogene Diffuse axonal Necrotic softening the Hemorrhage from damaged
sis injury substance of brain artery or vein from lesion of
hematoma
Clinical Short period of Prolonged disturbance of Meningeal symptoms, focus of
picture consciousness consciousness, focal neurological disturbances,
disturbance neurologic the persistent worsening of state
disturbance
X-ray No changes More frequently no More frequent break of bones of
changes skull
CT of the No changes Focus of decrease Region the increased density
head density (softening) (hematoma)
Treatment Symptomatic Treatment of brain Surgical removal of hematoma
therapy edema, Symptomatic
therapy